Thesis (MFamMed) Stellenbosch University, 2011. / ABSTRACT: Background: The initiation of antenatal care (“booking”) is universally recommended in the first trimester. While working in the Michael Mapongwana antenatal clinic (ANC) in Khayelitsha, the researcher noticed that late booking was prevalent, with consequent impaired antenatal care and increased potential for adverse outcomes. The objective of this qualitative study was to understand why women book late at this specific ANC. Methods: Twenty-three in-depth, open-ended interviews were conducted with 23 late bookers (i.e. who booked after 18 weeks) who attended the ANC between June and October in 2009. The interviews were recorded, transcribed, and analysed according to the “Framework” model. Results: The mean gestational age at booking was 26,4 weeks (range: 20 to 34 weeks). The majority were multigravid, unmarried and unemployed. A high incidence of previous or current obstetric problems was noted. Important personal barriers included ignorance of purpose of antenatal care, ignorance of ideal booking time, and denial or late recognition of an unplanned pregnancy. Provider barriers appeared to be significant, especially the cumbersome booking system, absence of an ultrasound service, and perceived poor quality of care. Conclusion: A combination of personal and provider barriers contributed to late booking at this clinic - it seems that the perceived effort of attending this antenatal service outweighed the perceived value thereof. Provider barriers should be addressed by accommodating patients’ needs, optimising nurse-patient interaction, provision of an ultrasound service and improvement of the booking system. Public awareness of early booking and the holistic value of antenatal care should also be enhanced.

Background: Antenatal care is essential care that assists in maintaining a state of good health for the woman and her unborn baby. Globally the use of antenatal care services remains a challenge and this tendency is closely associated with maternal and neonatal mortalities and morbidities. South Africa has adopted a free service policy for pregnant women, their infants and for children up to the age of six. Despite this policy, the problem of limited utilisation of antenatal care services by pregnant women is still observed in this country and is associated with increased maternal and neonatal mortalities and morbidities.The purpose of the current proposed study was to explore and describe the reasons for limited utilisation of antenatal care services in the Mnquma sub-district, and to develop guidelines to assist the midwives to encourage the use of antenatal care services. Objectives:To explore and describe the reasons for the limited utilisation of antenatal care services by pregnant women at Mnquma sub-district.To explore and describe the knowledge of antenatal care services by the pregnant women.To develop guidelines to facilitate empowerment of midwives to enhance utilisation of antenatal care services by pregnant women in the Mnquma sub-district in Eastern Cape Province. The study was conducted in Mnquma sub-district during the months of July to January in 2016 using a qualitative, exploratory, descriptive and contextual research design. The research population were post-delivery women and the purposive sampling was used to identify women who met the stated criteria. One-on-one audio-taped semi-structured interviews were conducted and field notes were kept to justify some of the themes identified. Thirteen interviews were conducted and transcribed verbatim. Collected data was analysed using Tesch’s data analysis method. Trustworthiness was maintained through the standards of truth value, credibility, transferability, dependability and conformability. The ethical considerations of beneficence, justice, autonomy, non-maleficence and veracity were maintained. From the findings it emerged that the participants raised various concerns with regard to barriers influencing limited utilization of antenatal care services. The participants had limited knowledge of antenatal care services. Furthermore, participants recommended some solutions to enhance utilization of antenatal care services. Recommendations were made with regard to clinical practice, nursing education and nursing research. Guidelines were formulated to assist midwives to enhance the utilization of antenatal care services by pregnant women in the Mnquma sub-district in the Eastern Cape.

The general health status of pregnant women depends largely on the quality of the antenatal services available to them. The provision of good antenatal services ensures early detection and prompt management of any complication or disease that may adversely affect pregnancy outcome. In order to ensure high quality care, antenatal services need to be evaluated at regular intervals, both from provider and client perspective, to ensure their effectiveness in improving the health status of pregnant women. The midwife, as the first contact person for most pregnant women attending antenatal clinics in South Africa, has the potential to play a major role in improving the health status of these women. However, for the midwife to be effective in achieving this, antenatal services need to be effectively utilized by women. One of the factors that affect utilization of any service is client satisfaction with the service being rendered. This study, therefore, explores the perceptions that pregnant women have of the care that they receive from midwives at the selected antenatal clinics. The objectives of the study are to: {u100083} Explore and describe the perceptions and experiences of pregnant women attending antenatal clinic regarding the care they receive from midwives. {u100083} Make recommendations to assist registered midwives in optimizing the accompaniment of women during the antenatal period. A qualitative, descriptive, exploratory and contextual design was used for the study. The sample was chosen from the target population by means of purposive sampling and data was collected through unstructured interviews with the participants. Before data collection, permission was obtained from the Eastern Cape Department of Health and the Nursing Service Manager of the Gateway clinic, in the district hospital where the research was conducted. The Nursing Service Manager was acting as a Medical Superintendent at the time of the study. Written, informed consent was obtained from all participants before conducting interviews. Trustworthiness was ensured by means of Guba’s model throughout the study, and the aspects of truth value, applicability, consistency and neutrality were considered. Tesch’s eight steps of data analysis were used to analyze the data collected, and four main themes were identified namely: • Women perceive midwives as considerate and knowledgeable • Women perceive midwives as lazy and rude • Women experience mixed emotions about the care they receive from midwives • Though their experiences, women identified certain needs in the services and care they received at the clinic. Conclusions were drawn and recommendations for midwifery practice made based on the results of the study, with the aim of improving antenatal services rendered to pregnant women.

Submitted in fulfillment of the requirements for the Degree of Master of Technology in Nursing, Durban University of Technology, 2014. / Brief background to the study The national guidelines for maternity care in South Africa recommend that a standardised maternity case record be used by all facilities at all levels of care in order to improve the quality of care for pregnant women. According to the National Department of Health, this will facilitate continuity and quality of care for women during pregnancy, labour and post-partum. Aim of the study The aim of the study was to assess whether the implementation of the new maternity case record has improved the quality of care for pregnant women. Methodology An exploratory, descriptive study using both quantitative and qualitative design was used to conduct the study. Data was collected through a retrospective record review using a checklist for the quantitative strand, and from midwives using unstructured interviews for the qualitative strand. The quantitative data set was analysed using the Statistical Package for the Social Sciences version 21.0 and the qualitative strand was analysed using the Tesch’s method of data analysis. Results The results of the record review revealed that although the recording was done fairly well, there were a number of activities and interventions that were recorded poorly or not recorded at all in some primary health care clinic. The midwives verbalised that many mistakes and mismanagement of ante-natal care clients emanated from the structure and the design of the new maternity case record. Recommendations Recommendations include the following: communication of policies and protocols to the midwives should be done timeously, provision of in-service education and/or updates on new developments, strengthening of supportive supervision, the Nursing colleges be kept up-to-date with new developments in nursing practice and that a broader study involving other districts and provinces be conducted.

Submitted in fulfillment of the requirements for the degree of Master of Technology: Environmental Health, Durban University of Technology, Durban, South Africa, 2016. / South Africa, like many other developed countries, is challenged by the under attendance and delay in initiation of antenatal care (ANC) services among pregnant adolescents. Adolescents are more vulnerable to pregnancy related complications, which may contribute to maternal and child mortality and morbidity. This study aimed at evaluating the under attendance and/or delay in initiation of ANC services among young pregnant adolescents (13-16 years old) as a risk for adverse maternal and birth outcomes. The research was based at a district hospital on the North Coast of Kwazulu-Natal. A retrospective review of all young adolescent (13-16 years old) maternity case records for the period from 2011-2013 was conducted. Data collected included ANC trends in attendance, obstetric and perinatal outcomes. A total of 314 pregnancies were recorded among young adolescents at this single hospital over a period of 3 years. Adolescent pregnancy was associated with a risk of late ANC booking and reduced ANC visits. The prevalence of anaemia (32%) was relatively high among the girls. Fifty percent of all adolescents received episiotomies while, 45(14%) experienced perineal tears. Logistic regression models found that the condition of perineum was significantly associated with HIV status (OR= 0.36; 95% CI=0.16; 0.84; p<0.05). HIV positive mothers were more likely to have an intact perineum post-delivery. However, HIV positive adolescents were twice as likely to be diagnosed with anaemia compared HIV negative mothers (results not significant). Underutilisation of ANC (i.e less than 4 visits) was significantly associated with lower gestational age (< 37 weeks) (OR=2.64; 95% CI=1.04; 6.74; p<0.05). Fifteen percent of young mothers delivered early (< 37 weeks), 10% delivered babies with a low birth weight (< 2500g) and 15% of the neonates suffered fetal distress. Low birth weight, low Apgar scores as well as the incidence of maternal anaemia and Pregnancy Induced Hypertension (PIH) were found to be related to late ANC booking. Qualitative findings highlighted the perceived barriers of ANC by pregnant adolescents. Interviews identified the following as factors that hindered access of care; financial barriers, attitudes of Health Care Workers (HCW), system barriers and fear of HIV testing. Urgent population based strategies are required to encourage timeous initiation of ANC among adolescents. Strengthening of health education programs on the benefits of ANC attendance among adolescents can be utilized as part of an approach to address the current public health concern. / M

submitted in fulfillment of the requirements for the Doctoral Degree in Nursing, faculty of Health Sciences, Durban University of Technology, Durban, South Africa, 2016. / Globally antenatal care is advocated as the cornerstone for reducing children’s deaths and improving maternal health. The World Health Organization designed and tested a Focussed Antenatal Care model for the developing countries to improve their quality of antenatal care services. South Africa has not successfully implemented this approach, referred to by South Africa as the Basic Antenatal Care approach. A convergent parallel mixed methods design was used to assess how the Basic Antenatal Care approach was implemented in the eThekwini district. Data were collected from 12 Primary Health Care clinics using observations, retrospective record reviews and semi-structured interviews conducted with pregnant women. The quantitative data was analysed using version 21.0 of the Statistical Package of Social Services and qualitative data was analysed using Tech’s method of data analysis. The Basic Antenatal Care approach was not being successfully implemented in the Primary Health Care clinics. Several aspects of planning, people, processes and performance were not done according to the Basic Antenatal Care Principles of Good Care and Guidelines. Although good communication was observed between the clinic staff members and the referral institutions, communication problems existed between the Primary Health Care clinics and the Emergency Medical Rescue Services and also with the pregnant women. Antenatal care and delivery plans and the midwives’ counter checking of maternity charts were not recorded. Some pregnant women had positive perceptions about the antenatal care services but others had negative perceptions. Recommendations pertaining to institutional management and practice, nursing education and research were made. A tailored practice framework and an implementation guide were developed based on setting and client-specific factors to facilitate the implementation of the Basic Antenatal Care approach. The framework highlights the importance of cooperation between management and administration, in-service education and skills development departments/units and the operational level. Effective implementation of the Basic Antenatal Care approach could help to reduce South Africa’s high maternal and neonatal mortality rates. Thus the tailored practice framework and implementation guide, developed as part of this study, could help to improve maternal and neonatal health-related outcomes in South Africa. / D

Thesis (M. Cur.) --University of Limpopo, 2015 / The purpose of this study was to determine the factors that were contributing to selfreferrals of antenatal women at the Dilokong Hospital in the Tubatse Local Municipality. By employing a quantitative, non-experimental research method, 360 women completed and submitted a structured questionnaire. Validity and reliability were insured by pre-testing the data collection instrument on respondents who were not part of the main study. Data was analysed by using the SPSS and Excel computer programs with the assistance of a statistician. The age group between 21 and 30 years 197 (54.7%) was larger than the other age groups. Primigravida women represented less than half 147 (40.3%) of the respondents. These women were also supposed to be referred to the hospital for delivery; however, only 23.3% of the women were referred to the hospital for delivery. The choice of the delivery site was influenced by a lack of women’s knowledge about the referral system and of services offered at the clinics, as well as the unavailability of doctors, midwives, food, equipment, enough space for delivery at the clinics, and the perceptions that nurses and midwives were rude. The government should ensure that the clinics are provided with adequate human resources and other resources that are needed for providing these health services. Pregnant women should be given referral letters and information with regard to where they are supposed to deliver. Key concepts: Antenatal women, self-referral, referral system, and Primary Health Care (PHC).

Delayed access to antenatal care (ANC) has been linked to maternal and foetal mortality and morbidity. Early and regular attendance of antenatal care by pregnant women is very important as it could identify birthing complications and includes amongst others, measuring of blood pressure to exclude pregnancy induced hypertension and measuring of weight to exclude intrauterine growth restriction. The purpose of the study was to explore the factors contributing to late antenatal booking around Thulamahashe local area so that interventions can be done to ensure that all pregnant women start antenatal care as soon as they miss a period, at twelve weeks at the most or before 20 weeks of gestation. The study was conducted at Thulamahashe local area which consists of 4 eight hour clinics and 1 twenty- four hours community health centre, at Bushbuckridge sub district, Ehlanzeni district, Mpumalanga province in South Africa. Data was collected using a researcher designed questionnaire which is a list of questions which were asked from respondents and which gave indirect measures of the variables under investigation. The structured questionnaire consisted of both open and close ended questions, which were used to collect information directly from pregnant women. The population of the study was pregnant women who had started antenatal care after 20 weeks of gestation, who were 18 years and above. The sample size consisted of 25 pregnant women who had booked late for antenatal care who were drawn from each facility by simple random sampling method and the total sample size was 127 respondents. The results indicated that most women initiated ANC later than the recommendations by World Health Organization (WHO) which is less than twelve weeks of gestation. Factors that were identified as associated with late antenatal booking were midwives’ attitude distance to the clinic, poor infrastructure, unplanned pregnancy, lack of education and unemployment. / Health Studies / M.A. (Health Studies)

M.Cur. / The primigravida's experience of childbirth is influenced by the knowledge and expectations she has of childbirth. Her expectations of childbirth are based on the information she got from the antenatal clinic, the nursing staff, her mother, friends and family. The purpose of this research was to determine the knowledge and expectations the primigravida has of childbirth. An exploratory, descriptive design was used within the context of an academic hospital in Johannesburg. The survey method was used. The method of research firstly consisted of a literature study of the primigravida's knowledge and expectations of childbirth. This was done in order to put the problem in perspective and also to serve as a theoretical framework for the study. Secondly, a structured questionnaire was used to make a survey of the primigravida's knowledge and expectations of childbirth. The test sample comprised all white primigravidas between the ages of 15 and 39 years with a pregnancy duration of 37 weeks and more who visited the antenatal clinic of an academic hospital in Johannesburg. Over a period of 11 weeks, from 15 october to 30 December 1989, 29 primigravidas participated in this research project. The questionnaires were completed with their visit to the antenatal clinic and then returned to the clinic staff. Descriptive statistics and frequency tables were used to interpret the results of the research. From this research it is clear that the respondents had insufficient knowledge of childbirth and the handling of pain during childbirth. This insufficient knowledge can mainly be attributed to the poor attendance of antenatal . preparation classes, inadequate professional counselling and the mother of the primigravida as the primary source of information on childbirth. The respondents, however, had realistic expectations· with regard to their handling of labour, as well as of the role of the midwife and the doctor.

This study explored and described the strategies used by nurses to manage newly diagnosed HIV positive pregnant women who do not return to the clinic within a month following diagnosis, for continuity of care. The main aim was to prevent mother-to-child transmission of HIV (PMTCT). Method: The study sites were two accredited antiretroviral- ante-natal care (ARV-ANC) clinics at the Dimbaza community health centre (CHC) and the East London Hospital Complex (ELHC) which comprises of Cecilia Makiwane and Frere hospitals, in the Buffalo City Metropolitan Municipality (BCM). The majority of health personnel at these clinics are professional nurses. An in-depth semi structured interview guide was used to collect data through focus group interviews from professional nurses who work in these units. They were required to share their experiences about intervention strategies used for newly diagnosed HIV- positive, pregnant women who fail to return for continuity of care within a month after diagnosis. Results: Follow up of these women is done by tracking them (by calling them; calling the clinic nearest to their homes and doing home visits). Decentralisation of further management and care to the nearest clinic was also cited, especially for the patients who stay far from these accredited sites. Family support was also mentioned as a strategy to intervene for the non-compliant patients. Challenges: The challenges that were encountered with these interventions include wrong contact details, wrong addresses and being evasive when visited at home. Another challenge cited was related to the stigma attached to the diagnosis and the tracking devices used, for example, the car as it is familiar to the community it serves. Despite known benefits for early initiation of HIV treatment newly diagnosed HIV- positive, pregnant women continue to refrain from accessing care after diagnosis, thus posing a risk to the transmission of HIV to the baby and further comprising their own health. They miss out on general HIV management and ante-natal care. Conclusion: The identified intervention strategies used by nurses to follow up newly diagnosed HIV- positive, pregnant women need to be reinforced and strategies put in place to control the related challenges for a better response by the patients.